Vernal Keratoconjunctivitis: an update focused on clinical grading system.

INTRODUCTION: Vernal keratoconjunctivitis (VKC) is a severe disease with a prevalence of < 1 case out of 10,000 in Europe, which occurs mainly in pediatric age and is characterized by a severe and often bilateral chronic inflammation of the ocular surface. The diagnosis is generally confirmed by the finding at the ocular examination of conjunctival hyperemia, papillary hypertrophy in the tarsal conjunctiva, giant papillae, papillae in the limbus region. OBJECTIVE: Aim of this review is to provide an updated overview on the disease focused on clinical grading system, searching papers published in the last decade on VKC in scientific databases. RESULTS: Currently there are no standardized criteria for diagnosis of VKC and there is no uniformity to define disease severity, which makes difficult to diagnose and treat the disease. CONCLUSIONS: Given the wide overlap of the symptoms of VKC with the allergic conjunctivitis, criteria of probable, possible or improbable diagnosis are needed, providing pediatricians with parameters useful for deciding whether to drive the patient to the ophthalmologist for diagnostic confirmation.

Predictivity of clinical efficacy of sublingual immunotherapy (SLIT) based on sensitisation pattern to molecular allergens in children with allergic rhinoconjunctivitis.

BACKGROUND: The diagnostic and therapeutic approach to grass pollen allergy is now possible by detecting specific IgE (sIgE) to its allergenic components. AIM: To evaluate the correlation between the sensitisation to different molecular Phleum pratense (Phl p) allergens and clinical efficacy of SLIT. METHODS: The pilot study included 36 patients affected by allergic rhinoconjunctivitis, all treated with SLIT actively. We performed serum analysis of sIgE to Phl p 1, 2, 4, 5, 6, 7, 11 and 12. The Average Rhinoconjunctivitis Total Symptom Score (ARTSS) and the Average Combined Score (ACS) were evaluated before and after one year of immunotherapy. RESULTS: Three different groups of sensitisation were defined based on the range of IgE reactivity to Phleum pratense allergens at baseline: group I (sIgE reactive to 1-3 allergens); group II (sIgE reactive to 4-5 allergens); and group III (sIgE reactive to 6-8 allergens). At T0 ACS was 1.79±0.18 in group I; 1.81±0.23 in group II; and 1.95±0.34 in group III. At T1 ACS was 0.85±0.55 in group I; 1.01±0.31 in group II; and 1.44±0.39 in group III. At T1 there was a significant improvement of ARTSS and ACS for group I (p=0.001). CONCLUSIONS: Sublingual immunotherapy with a grass pollen is efficacious irrespective of the patients' baseline sensitisation to either single or multiple grass pollen molecular allergens. We found that patients with few sensitisations have a greater improvement in combined symptom and medication score. SLIT improves the clinical course of allergic patients although new sensitisations may appear.

Craniofacial morphology and airflow in children with primary snoring.

OBJECTIVE: Sleep-disordered breathing (SDB) is among the most common diseases and includes a group of pathological conditions that form a severity continuum from primary snoring (PS) to obstructive sleep apnea (OSA). SDB presents a multifactorial etiology and in children, it is often linked to adenotonsillar hypertrophy, which may lead to an alteration of the breathing pattern. Therefore, several studies hinted at the existence of a correlation between SDB and the alteration of craniofacial growth. However, these studies concentrated on the most severe forms of SDB and little evidence still exists for the mildest form of SDB, namely PS. This preliminary study investigates the association between nasal airflow, measured through rhinomanometry, and cephalometric parameters in a sample of young children with PS. PATIENTS AND METHODS: A sample of 30 children with habitual snoring aged between 5 and 8 years was selected by a SDB validated questionnaire at the Pediatric Allergology and Immunology Center of "Sapienza" University of Rome, Italy. To assess the degree of nasal obstruction, all children underwent anterior active rhinomanometry while nocturnal pulse oximetry and polysomnography were used to characterize the SDB. Cephalometric analysis was used to evaluate relevant orthodontic parameters associated to the sagittal and vertical craniofacial development and to the position of the hyoid bone. RESULTS: We found a statistically significant association between the Frankfurt mandibular angle (FMA), which measures the total facial vertical divergence, and the severity of the airflow's obstruction (p = 0.014). CONCLUSIONS: The present study supports the association between the level of nasal obstruction in children with PS and the alteration of cephalometric parameters associated with the vertical craniofacial growth, thus placing the evaluation of craniofacial parameters in the growth period in a privileged position to determine an early diagnosis of a possible insurgence of sleep disorders.

HMGB1-Induced Cross Talk between PTEN and miRs 221/222 in Thyroid Cancer.

High mobility group box 1 (HMGB1) is an ubiquitous protein that plays different roles in the nucleus, cytoplasm, and extracellular space. It is an important DAMP molecule that allows communication between damaged or tumor cells and the immune system. Tumor cells exploit HMGB1's ability to activate intracellular pathways that lead to cell growth and migration. Papillary thyroid cancer is a well-differentiated tumor and is often used to study relationships between cells and the inflammatory microenvironment as the latter is characterized by high levels of inflammatory cells and cytokines. Anaplastic thyroid cancer is one of the most lethal human cancers in which many microRNAs and tumor suppressor genes are deregulated. Upregulation of microRNAs 221 and 222 has been shown to induce the malignant phenotype in many human cancers via inhibition of PTEN expression. In this study we suggest that extracellular HMGB1 interaction with RAGE enhances expression of oncogenic cluster miR221/222 that in turn inhibits tumor suppressor gene PTEN in two cell lines derived from human thyroid anaplastic and papillary cancers. The newly identified pathway HMGB1/RAGE/miR221/222 may represent an effective way of tumor escape from immune surveillance that could be used to develop new therapeutic strategies against anaplastic tumors.

Serum resistin levels in children with primary snoring.

Primary Snoring (PS) has been positioned at the milder end of the Sleep-Disordered Breathing severity continuum characterized by snoring and it is usually underestimated. PS is defined as snoring without apnea, frequent arousals, or gas exchange abnormalities and recent studies demonstrated that children with PS have increased blood pressure and reduced arterial distensibility. The association between adipokines and SDB has been recently investigated, though most of the studies were focused on OSAS where intermittent hypoxia characterizing the disease may lead to an inflammatory cascade and to the release of several adipokines, contributing to oxidative stress. Resistin, initially described s an adipokine increasing insulin resistance, has been recently identified as a novel important member of the cytokine family involved in the regulation of inflammation. The aim of our study was to investigate circulating resistin levels in normal weight children with PS. Sixty-five children of normal weight aged between 4 and 14 years of age were selected for habitual snoring. Children with positive polysomnography were excluded from the study. Serum resistin levels were detected in all children with PS. Thirty-three healthy non-snorer children with similar age, sex and BMI were selected as a control group. A significantly higher level of resistin was observed in patients with PS compared to the control group (4.67±1.91 ng/ml vs 3.98±1.58 ng/ml; p<0.01). Patients with inconclusive pulse oximetry showed significantly higher resistin levels than those with negative recordings recordings (5.29±1.91 ng/ml vs 4.20±1.93 ng/ml; p<0.008). Moreover, there was a significant increasing trend between sieric adipokine level and the frequency of snoring (p<0.006). Our results suggest that systemic inflammation and oxidative stress may also play a significant role in the pathophysiology of PS.

Anti IgE antibody as treatment of allergic bronchopulmonary aspergillosis in a patient with cystic fibrosis.

Allergic bronchopulmonary aspergillosis (ABPA) occurs in 7-9% of patients with cystic fibrosis (CF) and causes a worsening of lung function and respiratory symptoms. Standard treatment of ABPA consists of oral steroids; however, higher corticosteroid therapy associated to antifungal agent (itraconazole) long-term treatments are often required to reduce respiratory exacerbations and to prevent progressive lung damage. Here we describe the case of a girl with CF who experienced clinical and functional improvement over 12-months treatment with omalizumab. At birth, our patient was diagnosed with mild-to-moderate CF and from childhood she underwent annual cycles of antibiotic and corticosteroid therapies. At 12 years, she presented with a worsening respiratory condition, asthma symptoms and reduced lung function (FEV1 of 78%). Blood tests showed an increased concentration of plasma total IgE and positive specific IgE antibodies to Aspergillus fumigatus; allergic skin tests were also positive for A. fumigatus. The patient started steroid therapy but had impaired glucose tolerance due to long-term steroid use. Subcutaneous omalizumab 300 mg every two weeks was initiated and after 14 weeks she had improved respiratory symptoms (FEV1 99%) and a marked reduction in the use of systemic antibiotic and corticosteroid therapies. No side effects were reported. Our case shows that therapy with omalizumab for a prolonged period can resolve symptoms of asthma.

Risk factors affecting quality of life in a group of Italian children with asthma.

The measure of Quality of Life (QoL) has become one of the most important criteria used to assess the impact of chronic illness, such as asthma, on the patient’s daily life, in adults and children alike. The objective of our open observational study was to measure the QoL and analyze several factors that potentially affect QoL, such as symptoms and functional respiratory parameters, in a cohort of children with asthma. One hundred and twenty-seven children with asthma, 6 to 14 years of age, living in the city of Rome, were enrolled as outpatients. They were subjected to Skin Prick Tests (SPT), underwent spirometry and filled out the Pediatric Asthma Quality of Life Questionnaire (PAQLQ). One hundred and eleven children were diagnosed with intermittent asthma, 12 (10%) with mild asthma, and four with moderate persistent asthma. Ninety-six children had a positive SPT. The mean total score of QoL, obtained from the questionnaire, was 5.4 (∓1.2 SD). Two QoL groups were created. Children with total QoL score <5.5 were included in the “Lower QoL” score group while children with total QoL score ≥ 5.5 were included in the “Higher QoL” score group. Children in the Higher group and their mothers had a higher mean age, suffered from fewer asthma exacerbations during the year preceding the study, and showed a higher mean value of forced expiratory volume (FEV1) compared to the children in the Lower category. Using Logistic regression we identified the main factors that may affect QoL as FEV1, symptoms in the previous year and mother’s age. QoL is correlated with the frequency of asthma exacerbations and FEV1 values. Furthermore, our research shows that a significant impairment of QoL may also occur in patients with normal lung function, pointing out the importance of evaluating QoL in all children with asthma.

The growth of Streptococcus mutans in different milks for infant feeding.

After birth various bacterial species, mainly streptococci, colonize the oral cavity and are frequently isolated from carious lesions in children. Previous studies suggest that an earlier colonization of a child's mouth by cariogenic organisms might be related to a higher risk of caries. The aim of this study is to assess the influence of different milks for infant feeding on the growth of Streptococcus mutans (SM) colonies. Three human milk samples from three different mothers and five infant formulas were tested. To prepare the bacterial inoculum, SM was grown in Brain Heart Infusion broth for 18 hours at 37°C in microaerophilic atmosphere. The growth of SM was determined immediately after the inoculation of milks (T0) and after 24 hours (T24) of incubation. After 24 hours of incubation (ΔT= CFUs/ml at T24 – CFUs/ml at T0) the bacterial growth changes were different among milks. Among the complementary milks tested, ΔT of formulas supplemented with Lactobacillus reuteri and with Bifidobacterium lactis was lower than those of non-supplemented formula. In conclusion, on the basis of the reduced SM growth in milks supplemented with probiotics, we may speculate that these formulas have a preventive effect on the development of caries in children.

The evaluation of adenoid hypertrophy and obstruction grading based on rhinomanometry after nasal decongestant test in children.

OBJECTIVES: Adenoid hypertrophy (AH) is a very common problem in children. Nasal Fiberoptic Endoscopy (NFE) represents the gold standard method to diagnose AH. Rhinomanometry represents a valid diagnostic support. The aim of our study was to analyze the grade of nasal obstruction caused by AH, in a group of children, with rhinomanometry standard and after ND test versus NFE. PATIENTS AND METHODS: Two hundred and eighty-four of 300 collaborative children, diagnosed as chronic oral breathers, were enrolled. All children underwent a complete physical examination, anterior active rhinomanometry and a second rhinomanometry after the administration of the nasal decongestant (ND) xylometazoline. All children were evaluated using Nasal Fiberoptic Endoscopy (NFE). RESULTS: At rhinomanometry nasal obstrucion was found of grade 1 in 102 (35.9%) children, of grade 2 in 41 (14.4%), of grade 3 in 52 (18.3%), of grade 4 in 37 (13%) and of grade 5 in 52 (18.3%). Those patients were tested also with rhinomanometry after ND: grade 1 in 108 (38%) children, grade 2 in 52 (18.3%), grade 3 in 56 (19.7%), grade 4 in 23 (8.1%) and grade 5 in 45 (15.8%). At NFE: 83 (29.2%) patients presented a grade 0, 73 (28.7%) a grade 1, 51 (17.9%), 34 (11.9%) a grade 3 and 43 (15.1%) a grade 4. Comparing the grade of nasal obstruction in NFE and in RM after ND we found a great correlation for grade 1 and grade 5 (respectively 84.3% and 79,1%, p < 0.001) and low correlation for the others grades of obstruction. When compared to NFE, rhinomanometry test after ND had 81.1% sensitivity and 84.3% specificity. Operating Characteristic (ROC) curves were derived using data related to rhinomanometry vs NFE, and to Rhinomanometry after ND vs NFE. CONCLUSIONS: Rhinomanometry after ND, compared to rmhinomanometry, is more specific and useful to evaluate nasal obstruction due to AH in children. RM after ND is a great tool to assess the severity of nasal obstruction. In fact, the minimum and maximum degrees of obstruction to the RM after ND correlate significantly (p < 0.01) with those of NFE.

Efficacy of sublingual specific immunotherapy on allergic asthma and rhinitis in children's real life.

BACKGROUND: Sublingual-specific immunotherapy (SLIT) is considered as a valid treatment of respiratory allergies. AIM: We performed a case-control study to evaluate the effect of SLIT in children with allergic asthma and rhinitis. PATIENTS AND METHODS: The study plan included 140 patients (age 6-14 yr, 43% girls and 57% boys) presenting allergic rhinitis and/or asthma, 70 treated with SLIT actively for three years and 70 controls never treated with specific immunotherapy (only symptomatic drugs). Rhinitis Symptom Score (RSS), Asthma Symptom Score (ASS) and Medication Score (MS) were evaluated at beginning and during the 3 years of immunotherapy. results: There was a significant improvement of RSS (mean ± SD) in the SLIT group: baseline 5.31 ± 2.01, third year 1.38 ± 1.06 (p < 0.0001 vs baseline). CONTROL GROUP: baseline 5.00 ± 1.08, third year 4.68 ± 1.152 (P » NS). ASS (mean ± SD) in the SLIT group: baseline 4.09 ± 2.21, third year 1.23 ± 1.4 (p < 0.0001 vs baseline). CONTROL GROUP: baseline 4.04 ± 2.46, third year 3.62 ± 2.26 (p » NS). MS (mean ± SD) in the SLIT group: baseline 3.30 ± 1.4, third year 0.88 ± 1.26 (p < 0.0001 vs baseline). CONTROL GROUP: baseline 3.19 ± 1.23, third year 3.39 ± 1.12 (p » NS). There are no statistically significant differences among monosensitized/polysensitized patients and at different age ranges. None of the patients included reported severe systemic reactions or anaphylaxis. CONCLUSIONS: During the treatment, the active group showed sustained reductions in mean asthma and rhinitis symptom scores when compared with controls to confirm the efficacy and safety of sublingual immunotherapy.

Habitual snoring in children with previous allergic sensitization.

Previous studies have reported a high prevalence of allergy in children with Habitual Snoring (HS), but the relationship between allergy in the early years of life and the subsequent development of this Sleep Disordered Breathing (SDB) is yet to be elucidated. The purpose of the present study was to determine the role of early, under 36 months of age, allergic sensitization to food (with or without sensitization to airborne allergens) in determining the development of HS 8-10 years after. One hundred and forty-eight children (10-14 years, mean age 12 years) with a history of food allergy were selected. Under the age of 36 months, atopic status was assessed by skin prick test for a panel of airborne and food allergens. Questionnaires filled in by parents were used to collect information on children's snoring and associated symptoms. HS was defined as snoring three or more times per week. At 1-3 years of age 54 children were positive to food allergens alone, and 94 were positive also to airborne allergens. After 8-10 years of life, when patients were aged between 10 and 14 years, habitual snoring was reported in 37 children. Furthermore, among the 54 children under three years of age sensitized only to food, 8 became HS while of the 94 children sensitized to both food and inhalants allergens 29 developed HS. The difference between those two groups was statistically significant (p=0.04). We reported a significant risk of developing HS in children with early allergic sensitization. Specifically this risk was higher when food allergy was associated with inhalant allergy. The onset of upper airway inflammation due to allergic triggers in subjects under three years of age may be related to the subsequent development of SDB after 8-10 years.

Vernal keratoconjunctivitis: atopy and autoimmunity.

BACKGROUND: Vernal Keratoconjunctivitis (VKC) is a rare chronic ocular inflammatory disease and it mainly affects boys in the first decade of life. Although it is a self-limiting disease, patients may present many phases characterized by an exacerbation of inflammatory symptoms with a consequent decline of the quality of life. PURPOSE: define the clinical and immunological profile of patients affected by VKC and investigate their familiar history of autoimmune disorders and their autoimmunity pattern. PATIENTS AND METHODS: 28 children were enrolled (20 males, 71%) aged between 4 and 14 years of life affected by VKC. Family history of allergic and immunological diseases was collected for each patient. In particular, it was asked whether some components of their families were affected by Hashimoto's thyroiditis, type I diabetes, psoriasis or rheumatoid arthritis and Systemic Lupus Erythematosus (SLE). All VKC children underwent a serological evaluation of anti-nuclear antibodies (ANA). RESULTS: A family history of immunological disorders was found in 46% of patients, 28% of Hashimoto's thyroiditis, 14% of type I diabetes, 14% of psoriasis, and 1 of Systemic Lupus Erythematosus. Furthermore, 35% of patients was ANA positive and they corresponded to patients with a higher ocular score and with the most important clinical symptoms. CONCLUSIONS: the detection of ANA positivity and of a familiar history of autoimmune disorders in a high percentage of children with VKC may help us to better understand the association of this ocular inflammatory disease with systemic autoimmune disorders and atopic condition.

Treatment of glaucomatous patients by means of food supplement to reduce the ocular discomfort: a double blind randomized trial.

BACKGROUND AND AIM: Chronic use of multi-dose eye drops containing preservatives, such as it may happen in patients affected by primary open angle glaucoma, often results in a damage of the ocular surface due to the inherent toxicity of preservatives, that with time may lead to a lacrimal dysfunction syndrome and eye dryness. PATIENTS AND METHODS: This double blind, randomized, pilot study was conducted on 38 glaucomatous patients suffering from dry eye induced by long-term use of eye drops preserved with BAK. RESULTS: Treatment of these patients with a food supplement containing an association of forskolin, rutin and vitamins B1 and B2 for 30 days increased significantly their OPI values and improved the symptoms of dry eye with respect to a placebo-treated control group. CONCLUSIONS: The association of forskolin, rutin and vitamins B1 and B2 appears to be protective for the ocular surface, contributing to restore a normal equilibrium of the tear film in those subjects in which toxic agents such as BAK had determined alterations of its homeostasis.

Serum levels of IL-17 in patients with vernal keratoconjunctivitis: a preliminary report.

BACKGROUND AND AIM: Vernal Keratoconjunctivitis (VKC) is a chronic and often severe form of bilateral tarsal and/or bulbar conjunctivitis. The purpose of the present study is to measure the Interleukin-17 (IL-17) serum levels in children with VKC evaluating the role of the systemic inflammation in patients affected by VKC. PATIENTS AND METHODS: Fifteen patients were enrolled with VKC aged between 6 and 10 years of life. Serum were obtained from the peripheral blood samples collected from all the children included in the study to evaluate serum level of IL-17. RESULTS: Serum levels of IL-17 were significantly higher in patients with VKC than in healthy controls (10.3 ± 9.36 pg/ml vs. 3.3 ± 6.20 pg/ml respectively; p < 0.04). CONCLUSIONS: The presence of a significantly higher level of IL-17 in patients with VKC suggests a possible role of this cytokine in the pathogenesis of VKC. Further studies on larger samples of patients are warranted to confirm These findings in order to identify new possible therapeutic targets.

A survey on features of allergic rhinitis in children.

OBJECTIVE: A number of epidemiologic studies evaluated the prevalence of allergic rhinitis (AR), but few data are available on its different clinical presentations. We addressed this survey to assess the features of AR in children and adolescents. METHODS: Thirty-five centers in Italy included 2623 pediatric patients with rhinitis, of whom 2319 suffered from AR, while 304 had other kinds of rhinitis. For each patient a standardized questionnaire was filled in, including ARIA classification, the duration of symptoms, the allergen identified as clinically relevant, the co-morbidities, the kind of treatment, the response to treatment, the satisfaction with the treatment, and the feasibility of allergen immunotherapy (AIT). RESULTS: Of the 2319 patients, 597 (25.7%) had mild intermittent, 701 (30.2%) mild persistent, 174 (7.5%) moderate-severe intermittent, and 773 (33.3%) moderate-severe persistent AR. The allergens most relevant were grass pollen and dust mites. The most frequently used drugs were oral antihistamines (83.1%) and topical corticosteroids (63.5%). The response to treatment was judged as excellent in 13.5%, good in 45.1%, fair in 30.8%, poor in 10%, and very bad in 0.6% of cases. The satisfaction with treatment was judged as very satisfactory in 15.2%, satisfactory in 61.8%, unsatisfactory in 22.4%, and very unsatisfactory in 0.5% of cases. AIT was considered indicated in 53.1% of patients with mild intermittent, 79.2% of moderate-severe intermittent, 72.6% of mild persistent, and 82.7% of moderate-severe persistent AR. CONCLUSIONS: The limitation of this study is that the population was not unselected and this prevents epidemiological significance. These results offer confirmation of the adequacy of ARIA guidelines in classifying patients with AR and of the association of severe phenotype with lack of success of drug treatment.

Food allergy and the development of asthma symptoms.

Allergies are multifactorial diseases the onset of which depends also on genetic and environmental factors in early life. Thus, environmental factors can affect the immune response and modify lung development, thereby leading to asthma. The role of the factors used to date to predict asthma development is modest, and clinical criteria should always be considered in association with familiarity for atopy. The aim of this study is to evaluate the risk of asthma in a population with positive skin prick test (SPT) (which is a reliable marker of atopy) to food allergens, regardless of clinical manifestations in the early years of life. The cohort of children enrolled in our study who had a positive SPT to food in the first three years of life had a prevalence of asthma after 7-14 years, double that of the general pediatric population. This prevalence increased significantly in patients with SPT positivity for food and inhalant allergens. We identified a correlation between the sensitization profile in children under the age of 36 months and the development of asthma during a period of 7-14 years. This study confirms that early sensitization is an important risk factor for the development of asthma, particularly in association with sensitization to inhalants, and that the persistence of food sensitization in school-age children and adolescents is associated to more severe asthma.

The role of rhinomanometry after nasal decongestant test in the assessment of adenoid hypertrophy in children.

INTRODUCTION: Nasal respiratory obstruction is a very common otolaryngologic problem, often caused by adenoid hypertrophy (AH). Nasal fiberoptic endoscopy (NFE) represents the gold standard method to diagnose AH. Rhinomanometry represents a valid diagnostic support. OBJECTIVE: The aim of our study was to analyze the diagnostic value of rhinomanometry after nasal decongestant (ND) test for the evaluation of adenoid hypertrophy in children. MATERIALS AND METHODS: Seventy-one of 97 collaborative children, aged 6-12 years, affected by upper airways obstructive symptoms and diagnosed as 'chronic oral breathers' by a standardized questionnaire were included in the study. The first evaluation included a complete physical examination, anterior rhinoscopy and anterior active rhinomanometry. Patients with a positive rhinomanometry underwent a second rhinomanometry after the administration of the nasal decongestant (ND) xylometazoline. All children were evaluated using nasal fiberoptic endoscopy (NFE). RESULTS: At rhinomanometry a normal nasal airflow was found in 19 (26.8%) of children while nasal obstruction was underlined in 52 (73.2%). These patients were tested also with rhinomanometry after ND which confirmed the presence of nasal obstruction in 29 (55.7%) of patients. All patients included in the study underwent a NFE: 34 (47.8%) of them presented severe AH with an occlusion >75% of the choanal opening (grade ≥ 3) and 37 (52.2%) presented no or a mild form of AH (grade < 3). When compared to NFE, rhinomanometry test after ND had 82.7% sensitivity and 82.6% specificity. Positive predictive value and negative predictive value were 85.7% and 79.2%, respectively. Two receiver operating characteristic (ROC) curves were derived using data related to rhinomanometry vs NFE, and to rhinomanometry after ND vs NFE. CONCLUSIONS: Rhinomanometry after ND, compared to rhinomanometry, is more specific and useful to evaluate nasal obstruction due to AH in children, and it may be helpful to avoid unnecessary surgical procedures in children with temporary nasal obstruction.

An infant with diaphragmatic eventration and respiratory distress.

The authors report a rare case of partial diaphragmatic eventration in a 4-month-old infant with recurrent wheezing and low serum IgA values. Because of persistent respiratory symptoms after therapy with inhaled short-acting beta2 agonists and inhaled nebulized corticosteroids, surgery was undertaken to correct the defect. Despite surgery, the clinical symptoms did not improve. Consequently, gatroesophagel reflux was considered and the diagnosis was confirmed with pH-metry, after which the infant was started on a protonic pump inhibitor therapy (PPI), achieving clinical improvement. Our experience suggests that in infants with congenital diaphragmatic eventration who present with respiratory distress gastro-oesophageal reflux should be suspected, and PPI therapy should be started before planning surgery.